As National Breast Cancer Awareness Month draws near, you can feel the soft rumble of approaching awareness efforts, now unavoidably clothed in pink. For the past several years, the voices of those who question these efforts have become nearly as loud as those who support it. The rising din can make it a real challenge for consumers to know what to believe. It’s vitally important that all of us putting out messages about breast cancer be truthful about what we know, and just as important, what we do not.

One of the most visible debates not only in October but in breast cancer science is whether mammography’s potential to save lives has been exaggerated in an attempt to encourage women to get screened. One thing supporters and critics have to agree on is that the public should be told the truth not only about mammography’s potential, but also its limitations. By the same token, we must be honest about other potential risk factors for the disease.

So what to make of a blog post from Breast Cancer Action, a group focusing on environmental risks that is perhaps the most prominent critic of breast cancer awareness efforts? The post questions Susan G. Komen For the Cure’s focus on mammography.

At Breast Cancer Action, we bring a markedly different understanding of what action we all need to take—for ourselves, each other, our mothers, daughters, and granddaughters—to truly end the breast cancer epidemic. Komen’s faith in mammograms to bring the “end to breast cancer” is misplaced.

And later adds….

More women getting more mammograms is not going to end the breast cancer epidemic.

I think it is quite reasonable to question the heavy focus by groups like Komen, and by extension our own organization, on mammography. They are correct to point out that getting a mammogram cannot prevent a woman from getting breast cancer (not that anyone claimed it could) and that many women die from breast cancer even if it is diagnosed early. But then BCA does something that should give pause to those with a bit of knowledge about breast cancer risk.

Neither, of course, are healthy diets and good exercise regimes.

One of the ugly truths of breast cancer is that more than half of all breast cancers have no known cause and scientific evidence suggests that many cases are linked to exposure to environmental toxins.

While it is true that most cases of breast cancer have no known cause, the implication that exposure to environmental toxins is more important than diet and exercise would be –at the very least–an exaggeration. It minimizes the strong role diet and exercise play, and sends the message that environmental toxins are a proven risk. By doing that, BCA has taken part in the same practice they so vocally call out in other groups: using strong language to overstate the evidence to suit their own agenda.

By the same token, we should question the use of the term “breast cancer epidemic.” An epidemic is described as an unexpected rise in the number of events in a certain population. There is no breast cancer epidemic. The fact is, after increasing for more than two decades, female breast cancer incidence rates decreased by about 2% per year from 1998 to 2007, likely due at least in part to a decrease in the use of hormone therapy after the results of the Women’s Health Initiative were published in 2002.

Groups like Breast Cancer Action play a vital role in keeping all of us focused in our efforts in breast cancer. They keep us honest, ask challenging questions, and force all of us to look closely at what we say and what we do. But all too often, journalists and the public –often the same folks who question groups like Komen and the American Cancer Society– give activists a pass when they make questionable claims to pursue their own agenda.

It’s time to stop the hype, and give women information and advice we can all agree can lower their risk of breast cancer. That means paying attention to those risk factors most likely to get results; getting exercise, staying at a healthy weight, and eating a healthy diet. It also means getting answers to other potential environmental risks, like the thousands of chemicals we’re exposed to at home and at work. And finally, it means encouraging the appropriate use of screening tests that can detect cancer when it’s most treatable. Let’s agree that mammography has played a role in recent and gratifying drops in breast cancer deaths. The best estimates are it’s responsible for about a third of the drop in mortality. And while mammography is not the magic bullet that will end breast cancer forever, it’s an important part of the progress that’s been made. Mammography is a good test. We need a great test.

13 Responses to Breast Cancer: Just the Facts

Hi David,
I think you missed the point of my comment. We have no dispute about the known health benefits of diet and exercise on reducing one’s risk for breast cancer; however, I have to take issue with your downplaying of the connection between exposure to environmental toxins and increased risk of breast cancer on two levels:

1. Even those of us with access to an excellent pesticide and hormone-free diet and robust exercise plans are involuntarily exposed to a myriad of chemicals in our environment that are known or suspected carcinogens or endocrine disruptors that put women at risk for breast cancer. These chemicals are found in our everyday environments: methylparabens in cosmetics and personal care products and BPA in baby bottles, food container linings, and even sales receipts to name just a few ways they surround us. And this isn’t simply Breast Cancer Action’s point of view. The President’s Cancer Panel in Oct 2008 clearly stated: “The most direct way to prevent cancer is to stop putting cancer-causing agents into our indoor and outdoor environments in the first place.”

2. By only focusing on the benefits of individual diet and exercise, we lose sight of the social justice issues that limits access to affordable healthy food and regular exercise for many in our society. This last point is significant because unless we increase the focus of our attention around health inequities we fail to address the health of a growing segment of our population: namely underserved women of color.

We strongly feel the best approaches are a combination of individual AND societal changes so that EVERYONE has the option of limiting their risk of getting breast cancer. And although you question our use of the word epidemic, I’d say that after billions of dollars over the years has been raised to quell the tide of breast cancer with the result being a rising lifetime incidence from 1 in 20 in 1960 to 1 in 8 today, that’s an epidemic we best address. By Komen and ACS keeping to just the narrow actions of individuals we feel you’re only addressing a part of the picture. While women are dying, we need a call for action that takes into account the whole picture of what we need to do to reduce breast cancer incidence – and it needs a lot more than a yearly mammography, a piece of fruit and going for a run.
–Karuna Jaggar, Breast Cancer Action

Breast Cancer Action would like to issue a correction to our previous comment. We erroneously attributed the quote “The most direct way to prevent cancer is to stop putting cancer-causing agents into our indoor and outdoor environments in the first place” to the President’s Cancer Panel, when in fact it was from a consensus statement sent to the President’s Cancer Panel by the Collaborative on Health and the Environment. In April 2010 the President’s Cancer Panel did say that “The Panel was particularly concerned to find that the true burden of environmentally induced
cancer has been grossly underestimated” and “the American people—even
before they are born—are bombarded continually with myriad combinations of these dangerous
exposures. ” They urged the President “to use the power of [his] office to remove the
carcinogens and other toxins from our food, water, and air that needlessly increase health care
costs, cripple our Nation’s productivity, and devastate American lives.”

As a breast cancer survivor, I thank you for caring about preventing this disease. I disagree with your criticism of Breast Cancer Action’s statements. I do not at all think we are overestimating the risk of environmental toxins contributing to breast cancer. I think the American Cancer Society UNDERestimates the risk of environmental toxins and OVERestimates the benefit of diet and exercise.

My story is only one story, but I’ve heard many like it:

I was diagnosed with breast cancer at age 30, despite having no family history of the disease. I’m 5’3″, and I weighed 120 lbs. My adult weight has always been between 115 and 125 lbs., which means I have a great Body Mass Index (BMI). I had never in my life smoked a cigarette, had an alcoholic drink, or tried drugs, and I drank no coffee until age 29. I’ve never taken HRT. Getting 7-8 or more hours of sleep per night has always been a priority for me. I did not have an early menarche. For at least the decade leading up to my diagnosis, I had been eating a vegetarian, largely organic diet, rich in fruits, vegetables, and whole foods. I spent 2 years living on an organic farm, and for the past 6 years, I have purchased about 95% of my groceries at the local natural foods co op and farmer’s market. I even eat sardines and brussels sprouts! For several years leading up to my diagnosis, I regularly walked, did yoga, and trained in circus/trapeze, and I could do 10 consecutive pull-ups! Until my breast biopsy, I had been so healthy I hadn’t had a needle in me for 16 years, other than for dental work. My antioxidant levels were high. I could go on and on. If diet and exercise/lifestyle counts for so much, why did I still get cancer? I’ll never really know, nor will anyone. However, I spent the first 23 years of my life living in a town that had a breast cancer rate that was 20% higher than the rest of the state, which to me, suggests environmental toxins.

The work of the Breast Cancer Fund, Breast Cancer Action, Sandra Steingraber, Devra Davis, and the Silent Spring Institute have shown me the at least very probable link between breast cancer and environmental toxins. I’m sick of hearing “evidence is inconclusive, we need more studies” used as an excuse to ignore or minimize the risk of environmental toxins. Chemicals that we are all involuntarily exposed to via soil, water, air, food, smog, and household products should be proven to be safe before they are allowed to be manufactured, rather than assumed to be safe until proven otherwise. The latter is very dangerous.

As Breast Cancer Action points out, many people do not have access to healthy food or the ability to exercise regularly, due to social inequities in our society. The percentage of Americans living in poverty now is the highest its been since 1993, says Census Bureau data. Impoverished communities have fast food chains and convenience stores and Walmart, not Whole Foods and natural food co ops. I suppose poor people could get their exercise by walking up and down the Walmart grocery aisles 18 times each until they manage to find the tiny amounts of healthy food items hidden amidst entire aisles full of frosting, sweeteners, soda, chips, candy, and processed meats. I spent 15 minutes in the bakery section recently and was unable to find a single loaf of bread that did not list some form of sugar in the ingredients.

Please don’t tell me to exercise more and eat more vegetables. I did everything I possibly could to be healthy and still got cancer. I can’t do this alone! It takes so much more than just individuals changing their lifestyles. EVEN IF we all had enough time in the day to exercise regularly and the necessary time and space to do so, and the necessary access to healthy foods and the money to buy them, we are all still exposed to thousands of unregulated and untested chemicals in the environment on a daily basis, against our will. SERIOUSLY preventing the breast cancer epidemic – YES, epidemic – will require large scale institutional change.

This insistence on linking the environment, universally, to breast cancer is overreaching. Breast cancer rates are what they are because of diet, obesity, delayed childbearing, and hormone use. I think if the environment were *causing* all these cases of breast cancer, then people in general would be sick with a myriad of diseases that had clear links to our surroundings. It’s not like everyone is ingesting asbestos or high doses of radiation left over from an A-bomb.

So all in all, I think the epidemic of breast cancer is, plain and simple, due to excess estrogen caused by the aforementioned factors, not because a woman chose to buy her produce at Publix instead of Whole Foods.

David your statements are honest and reflective of the state of the art. BCAction is rather apartheid, and does not acknowledge a lot of FACTS when it comes to breast cancer and breast cancer treatment. 1. Mammography is not the villain it is made out to be – it does save lives, though clearly not enough. 2. The medical establishment is not trying to keep cancer patients sick because a “cure” isn’t profitable. 3. Indeed as you said, cancer rates dropped for the very first time all over the world when women stopped using hormone therapy. Now THERE’S a CAUSE of cancer for you!

Yes I think there is a lot of money to be made by pushing drugs on healthy people, etc. etc., and that is clearly not right. But I find it hypocritcial that people disparage the medical establishment and accuse them of “dishonesty” while acting like they know more, BUT at the same time, take advantage of the lifesaving advancements of modern medicine.

Numone,
There are many causes of cancer, and it’s probably a combination of many things…and we’ll probably never know for sure. Environmental toxins are not entirely to blame, of course, but neither are poor diet/obesity/delayed childbearing/hormone therapy, as my case illustrates.

I did not at all say or suggest that cancer is caused by “buying food at Publix instead of Whole Foods.” My point was that too much emphasis is placed on diet, and the problems with this are 1) Not everyone has access to or can afford healthy food; and 2) Eating quality, organic, healthy, whole foods isn’t enough anyway, because I (and many others) did that and still got cancer. Therefore, strategies to end the breast cancer epidemic must include 1) addressing the social inequalities that prevent access to healthy food, and 2) institutional change as well as individual change. I did everything possible for an individual to do to try and prevent cancer, and it wasn’t enough. Not when environmental toxins are so ubiquitous. Many of these environmental toxins are endocrine disruptors which mimic estrogen.

And for the record, I’m not “against” the medical establishment. I’m extremely grateful for the high-quality care I received from my doctors and everyone on my health care team.

Agree, no individual case of breast cancer has ever been 100% figured out. Yes population studies can determine risk factors, but not for the individual.

However, what I take issue with are claims based on weak science. And I think the links to environment/lack of organic “natural” food need better science behind them. I am well aware of the BPA concerns, and there are as many studies to spur concern as there are not. For example, a recent study called the “Majestic” Study did hourly blood tests of individuals after ingesting BPA and found negligible blood concentrations. Does that means it’s home free? Certainly not! On the contrary, a study in pregnant women reported in May that mothers whose blood levels were highest gave birth to offspring with wheezing and respiratory problems. So indeed, it’s a substance that needs to be studied further. But to go as far as to say it is driving the breast cancer epidemic is wholly lacking in proof.

Now let’s look at diet and the “organic is better” mantra. Most studies do indeed link diet to breast cancer, but it’s complicated. Most population and/or animal studies have found that alcohol intake, weight and calorie count matter the most, all leading to altered estrogen levels and metabolism among other things. Low fat diets, however, have not reduced the risk of primary or secondary breast cancers. But I most certainly agree (as you pointed out) that poorer women cannot afford more nutritious (and lower calorie) food and this no doubt explains some of the major differences in disease rates based on socioeconomic status. And while I do believe that poor diet/overweight is a major factor in the rising breast cancer rates in our industrialized, Western culture, I remain skeptical of “eat organic” recommendations. There are no conclusive answers on that. And you would probably have to do a randomized trial as big as WHI and consign one group to organic eating (ie buy every morsel of food you eat from Whole Foods or wherever) and the other to “standard” fare and then follow them for decades. That’s very difficult to do, and the results would probably not be as dramatic as some would hope for.

What I am more interested in is a refined understanding of the more obvious (and probable) causes of the higher breast cancer rates that have have surfaced in the last 60 years. Women are VERY different today than they were in the past: they have broken away from the old expectations of being only wives and mothers. However, early pregnancy (which is NO WAY recommended for any reason) was probably protecting our grandmothers’ generation as they married younger and had children younger. But today, starting with the Boomers, women have delayed childbearing or chosen not to have kids at all for their own (and certainly justified!) reasons. But from a strictly biological standpoint: having a child early cuts breast cancer by 2/3rds when compared to nulliparity/delayed pregnancy until after 30. In fact, one epidemiologist, Anthony Miller, hypothesized that maybe 25% of breast cancers are attributable to that factor alone. And add in the the other obvious hormonal factors like obesity and HRT (17% and 8% respectively) and you have a half of cases figured out. Now of course what about the remaining cases?

Well, that’s yet to be determined. Despite the seemingly high incidence in young women, breast cancer before the age of 40 is still rare. However, evidence IS mounting that many of the “unexplained” cases are indeed still linked to estrogen exposure, but finding that evidence has taken more digging and is not based on epidemiology but rather individual biological studies. For example, a surprisingly recent (maybe a decade ago) discovery about postmenopausal estrogen levels and high breast density have certainly started to close the gap on some of those unexplained cases in women with no obvious risk factors, posing a good 4-to-6-fold higher risk for women who have them. And for women of all ages, as David pointed out, exercising DOES lower risk considerably, again through reduced hormone levels. This explains why antiestrogen therapies (tamoxifen and aromatase inhibitors) have been so effective at warding off recurrences. Now in the end you might still ask – is the environment a driving force behind some of these cases or does it explain the hormonal milieu going on in the body of the woman who “did everything right”? Will there be eventual, solid evidence that certain industrial chemical exposures are responsible for some cases? Perhaps. But will they explain a majority (ie half as Karuna claimed)? Probably not. And certainly not more or even a lot more than the clear cut group of risk factors (old and new) already explain.

It is good to learn all the information about breast cancer so that the people will become aware of it and how to possibly prevent it. Thank you so much for sharing these facts about it. I had an incredible time reading it.